Elements of Chronic Disease Management

The following Chronic Disease Management (CDM) products and initiatives are designed to address systemic barriers and reduce the gap between current care and established evidence-based standards of care for specific diseases. These include strategies and elements for improving care in the health system, in communities, in organizations, in clinical practice and with patients.

• Business cases to identify economic and health outcome benefits based on evidence.
• CDM structured collaboratives to train and support integration of chronic care best practices into clinical practice. Collaboratives consist of physician-led teams, and participating practices focus on comprehensive patient care including:
  • adherence to clinical practice guidelines
  • use of flow sheets and other tools to enable planned patient visits
  • performance monitoring
• Patient registries for diabetes, asthma, hypertension, depression and congestive heart failure initially.
• Performance measures for health outcomes, patient satisfaction, costs and utilization of health services.
• Disease management approach to evidence-based practice guidelines on asthma, diabetes, hypertension, congestive heart failure, depression and chronic kidney disease.
• Private/public partnerships with the pharmaceutical industry to support the implementation of chronic disease management.
• Professional Development designed and delivered by B.C. physicians to enhance skills in self-evaluation, patient self-management coaching, and use of web-based and personal digital assistant (PDA) technology in clinical practice.
• Web-based access for patients and practitioners to information and tools to support them to manage chronic diseases. This includes a secure web site for practitioners providing information to help manage the care of their patients with chronic diseases.
• Shared care models - including support of general practitioners by specialists.
• Self-management training and supports for patients (e.g. BC HealthGuide, BC NurseLine), and patient input through surveys.
• Two-year pilot project testing impact of financial incentives on physicians' adoption of diabetes and congestive heart failure care that is consistent with clinical guideline recommendations. Jointly sponsored by B.C.M.A., B.C. Ministry of Health, and Society of General Practitioners of B.C.

Last Revised: February 14, 2007